And the Neo-BFHI Study Group Compliance with the Baby-friendly Hospital Initiative for Neonatal Wards (Neo-BFHI). A cross-sectional study in 36 countries. Ragnhild Maastrup, PhD, RN, IBCLC (Denmark) Laura N. Haiek, MSc, MD (Canada) And the Neo-BFHI Study Group

Disclosure statement The authors have no relationships to disclose relevant to this topic.

Background Historically neonatal wards present barriers to breastfeeding The Neo-BFHI Guiding Principles and Steps were published in 2012-13 and the standards and recommendations in 2015. Breastfeeding related policies and practices in neonatal wards are not well documented internationally, only Denmark and Spain have national surveys (Maastrup 2012, Alonso-Diaz 2016).

A confidential assessment tool, which was pilot testet twice in a total of 18 countries. http://www.ilca.org/main/learning/resources/neo-bfhi

Aim To measure compliance with the Neo-BFHI’s expanded Ten steps to Successful Breastfeeding, The Code, and three Guiding Principles in neonatal wards globally.

Methods Principal investigators: Ragnhild Maastrup, Denmark and Laura Haiek, Quebec, Canada. Country survey leaders in each country enrolling wards and ensuring data collection. Survey using a Self-Assessment questionnaire, based on the Neo-BFHI Self-Appraisal Tool. 15 different languages, most online. Pilot-tested in Quebec, Denmark, UK and France.

Methods Data collected February – December 2017 All levels of neonatal wards were eligible to participate Sent to head nurse or medical director of neonatal wards

917 neonatal wards (64% level 3) 20 1 5 2 2 6 917 neonatal wards (64% level 3) 36 low, middle, and high-income countries from all continents participated (yellow)

Analysis Partial and Overall Compliance scores: Based on 63 indicators for the GPs, Steps and Code Mean scores for each ward presented in a benchmark report Country (regional) and International scores presented as median scores

Calculation of scores for each GP, Step and the Code for an individual NICU Range 0 - 100

Results 917 neonatal wards (64% level 3) International median score 77 (Country range 52 - 91) Highest scores Guiding Principle 1 (respect for mothers) 100 Step 5 (breastfeeding initiation and support) 88 Step 6 (human milk use) 88 Lowest scores Step 3 (antenatal information) 63 Step 7 (rooming-in) 67

Results Figure from article

Figure from article

BFHI/non-BFHI Neonatal wards situated in a hospital ever-designated Baby-friendly had significantly higher Ward Overall scores [mean 83.2 (95% CI 82.0 – 84.3)] than wards in non-BFHI hospitals [mean 72.3 (95% CI 71.1 – 73.4)] (p<0.0001). This was also true for all Partial scores.

Income and Partial scores High-income countries had significantly higher scores for Guiding principle 2 (family-centered care) [median 83 (95% CI 79.1–87.7) versus 71 (95% CI 63.8 – 78.3), p=0.0023] Step 4 (skin-to-skin contact) [median 79 (95% CI 74.0 – 83.8) versus 63 (95% CI 48.3 – 77.7), p=0.0091] Step 5 (breastfeeding initiation) [median 87 (95% CI 84.5 - 89.7) versus 81 (95% CI 75.0 - 87.3), p= 0.0316].

Conclusion Country scores higher than 50 for all 36 participating countries demonstrate that neonatal wards around the world are working to support breastfeeding. The study indicates international readiness to expand Baby-friendly standards to neonatal settings. Hospital and governments should increase their efforts to promote, protect and support breastfeeding in preterm and ill infants. Neonatal wards may differ considerably in Neo-BFHI compliance, both within and across countries. Further research should include parents’ perspective, ensure participation of more low-income countries, and explore the effect of implementing the Neo-BFHI on breastfeeding outcomes.

Thank you for your attention Published September 10, 2018 Contact information: Laura N. Haiek Laura.haiek@msss.gouv.qc.ca Ragnhild Maastrup ragnhild.maastrup@regionh.dk